The 411 on Migraines: What Is a Migraine?

It begins as a throbbing pain on one side of your head. Light and sounds become unbearable, then your vision starts to blur. Most people suffer from some kind of headache at least occasionally, but migraines can be a crippling ailment that are often misdiagnosed as tension or sinus headaches. Fortunately, for the vast majority of migraneurs, the headaches can be treated and often prevented. In this two-part report, we’ll give you everything you need to know about migraines, and then examine how they can be prevented or reduced in frequency by non-pharmacologic means.

Am I having migraines?

Migraines are one of the leading causes of headaches, affecting 12 to 16 percent of the population, with women far more susceptible than men. They typically begin in childhood, adolescence or early adulthood, although some women may first experience migraines during menopause.

The pain of a migraine is typically severe, throbbing, and accompanied by nausea. The headache is almost always unilateral (confined to one side), generally around the eye or front of the head. However, migraines can also happen in the back of the head and neck and are often misdiagnosed as tension headaches because they are centered in the muscles. Nasal congestion can accompany migraines, which means they are also misdiagnosed as sinus headaches. The nasal congestion is actually caused by the activation of certain nerves during the migraine that leads to excessive mucous production.

Other common symptoms of migraines include dizziness and sensitivity to light, sound, movement, or certain smells. About 30 percent of patients will also experience an aura—visual abnormalities such as diminished vision, sparkling lights, or zig-zag patterns—that occur before the headache. Some patients may even experience double vision.

What causes migraines?

People who experience migraines show a strong genetic predisposition—a history of migraines in other family members is very common.

For a long time, we thought that migraines were a blood vessel disorder. Now we know that changes in the blood vessels is a secondary phenomenon; the primary problem is a nerve dysfunction. Activation of certain cranial nerves leads to inflammation around the blood vessels, which causes the excruciating pain.

Patients with migraines are usually able to identify specific triggers for their migraines. These include emotional upset or stress, certain foods or beverages, such as red wine, cheese, or chocolate, or—in women—their period. Many patients who can identify stress as a primary precipitant experience migraines right after the stress has resolved.

What is the course of a typical migraine?

A migraine evolves over several stages. It starts with a prodrome — you feel tired, irritated, or withdrawn and can experience a decreased ability to concentrate as well as mild nausea. Many recognize this first stage as a sign of what’s to come and take steps to mitigate the coming onslaught. The second stage is the aura, although many people don’t experience auras at all. The third stage is the migraine itself, followed by a postdrome, which is the same as the prodrome and can last hours or even days.

What type of treatment is available?

Migraine therapy falls into two distinct categories — acute management of a new or ongoing headache and treatment to prevent (or at least reduce the incidence of) future headaches.

Acute, or abortive, therapy is almost always pharmacologic. Drug treatments include simple analgesics (Tylenol, Advil, Aleve) and a class of drugs known as triptans. Triptans are prescription medications like Imitrex and Relpax, and have revolutionized our approach to the acute management of migraines. They’re available as oral pills, intranasal sprays, and injections and vary in potency, side effects, how quickly they act, and how effective they are at preventing a recurrence.

No one drug is a star in every category, so it’s important that you and your health care provider weigh the pros and cons of each of these drugs and decide which is best for you. Often these abortive therapies are combined with anti-emetics—medications that control nausea and also have a therapeutic impact on the headache itself. For patients whose migraines don’t respond to one of these interventions, oral steroids can often break the pain cycle.

Preventive therapy is indicated for patients with frequent and/or debilitating headaches, and includes prescription drugs, but also nutraceuticals, lifestyle modifications, and some fascinating new devices that are on the market. Explore these non-pharmacologic methods in the next installment in this series, Natural Migraine Relief.

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Malcolm enjoys being on the front lines of patient care, managing diagnostic and therapeutic challenges with a compassionate, integrative approach that stresses close doctor-patient collaboration. He is the author and chief editor of several best-selling medical textbooks and online resources, and has extensive expertise in managing a wide range of issues including the prevention and treatment of cardiovascular disease, diabetes, and sports injuries.
Malcolm graduated magna cum laude from Amherst College, received his MD from Duke University, and completed his residency in Internal Medicine at Harvard's New England Deaconess Hospital and Temple University Hospital. He joined One Medical from his national award-winning Internal Medicine practice in Pennsylvania and was an attending physician at The Bryn Mawr Hospital since 1986. He is certified through the American Board of Internal Medicine.
Malcolm is a One Medical Group provider and sees patients in our New York offices.

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